Halcinonide in the treatment of corticosteroid responsive dermatoses

Identification and structural characterization of major stress degradation products of halcinonide by liquid chromatography-high-resolution mass spectrometry

Halcinonide is a topical corticosteroid approved by the US Food and Drug Administration (FDA), known for its anti-inflammatory and antipruritic properties. The therapeutic benefits of halcinonide have rendered it an effective treatment regimen for various dermatological conditions such as psoriasis, dermatitis, and eczema. However, stability of the drug substance is a prerequisite in determining the therapeutic efficacy and plays a crucial role during formulation development and long-term storage. As corticosteroids are highly susceptible to degradation, the current study aims to expose halcinonide to different stress conditions and understand its stability behavior. An HPLC method was developed for the separation of halcinonide and its degradation products. Separation was accomplished in gradient mode using an Eclipse Plus C18 column (250 × 4.5 mm, 5 μm) with ammonium formate (10 mM, pH 6.5) and acetonitrile as the mobile phases. LC-Q-TOF/MS/MS studies were conducted on halcinonide, which led to the identification of degraded products using optimized mass parameters. A potential mechanistic degradation pathway for halcinonide, along with the major identified degradation products has been established. The chromatographic method that was developed has been validated in compliance with the Q2(R1) guideline of the International Council for Harmonization. ProTox-II was used to perform in silico toxicity studies in order to evaluate the toxicity potential of both halcinonide and the identified degradation products.

Strategies for using topical corticosteroids in children and adults with eczema

BACKGROUND

Eczema is a common skin condition. Although topical corticosteroids have been a first-line treatment for eczema for decades, there are uncertainties over their optimal use.

OBJECTIVES

To establish the effectiveness and safety of different ways of using topical corticosteroids for treating eczema.

SEARCH METHODS

We searched databases to January 2021 (Cochrane Skin Specialised Register; CENTRAL; MEDLINE; Embase; GREAT) and five clinical trials registers. We checked bibliographies from included trials to identify further trials.

SELECTION CRITERIA

Randomised controlled trials in adults and children with eczema that compared at least two strategies of topical corticosteroid use. We excluded placebo comparisons, other than for trials that evaluated proactive versus reactive treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods, with GRADE certainty of evidence for key findings. Primary outcomes were changes in clinician-reported signs and relevant local adverse events. Secondary outcomes were patient-reported symptoms and relevant systemic adverse events. For local adverse events, we prioritised abnormal skin thinning as a key area of concern for healthcare professionals and patients.

MAIN RESULTS

We included 104 trials (8443 participants). Most trials were conducted in high-income countries (81/104), most likely in outpatient or other hospital settings. We judged only one trial to be low risk of bias across all domains. Fifty-five trials had high risk of bias in at least one domain, mostly due to lack of blinding or missing outcome data. Stronger-potency versus weaker-potency topical corticosteroids Sixty-three trials compared different potencies of topical corticosteroids: 12 moderate versus mild, 22 potent versus mild, 25 potent versus moderate, and 6 very potent versus potent. Trials were usually in children with moderate or severe eczema, where specified, lasting one to five weeks. The most reported outcome was Investigator Global Assessment (IGA) of clinician-reported signs of eczema. We pooled four trials that compared moderate- versus mild-potency topical corticosteroids (420 participants). Moderate-potency topical corticosteroids probably result in more participants achieving treatment success, defined as cleared or marked improvement on IGA (52% versus 34%; odds ratio (OR) 2.07, 95% confidence interval (CI) 1.41 to 3.04; moderate-certainty evidence). We pooled nine trials that compared potent versus mild-potency topical corticosteroids (392 participants). Potent topical corticosteroids probably result in a large increase in number achieving treatment success (70% versus 39%; OR 3.71, 95% CI 2.04 to 6.72; moderate-certainty evidence). We pooled 15 trials that compared potent versus moderate-potency topical corticosteroids (1053 participants). There was insufficient evidence of a benefit of potent topical corticosteroids compared to moderate topical corticosteroids (OR 1.33, 95% CI 0.93 to 1.89; moderate-certainty evidence). We pooled three trials that compared very potent versus potent topical corticosteroids (216 participants). The evidence is uncertain with a wide confidence interval (OR 0.53, 95% CI 0.13 to 2.09; low-certainty evidence). Twice daily or more versus once daily application We pooled 15 of 25 trials in this comparison (1821 participants, all reported IGA). The trials usually assessed adults and children with moderate or severe eczema, where specified, using potent topical corticosteroids, lasting two to six weeks. Applying potent topical corticosteroids only once a day probably does not decrease the number achieving treatment success compared to twice daily application (OR 0.97, 95% CI 0.68 to 1.38; 15 trials, 1821 participants; moderate-certainty evidence). Local adverse events Within the trials that tested 'treating eczema flare-up' strategies, we identified only 26 cases of abnormal skin thinning from 2266 participants (1% across 22 trials). Most cases were from the use of higher-potency topical corticosteroids (16 with very potent, 6 with potent, 2 with moderate and 2 with mild). We assessed this evidence as low certainty, except for very potent versus potent topical corticosteroids, which was very low-certainty evidence.  Longer versus shorter-term duration of application for induction of remission No trials were identified. Twice weekly application (weekend, or 'proactive therapy') to prevent relapse (flare-ups) versus no topical corticosteroids/reactive application Nine trials assessed this comparison, generally lasting 16 to 20 weeks. We pooled seven trials that compared weekend (proactive) topical corticosteroids therapy versus no topical corticosteroids (1179 participants, children and adults with a range of eczema severities, though mainly moderate or severe). Weekend (proactive) therapy probably results in a large decrease in likelihood of a relapse from 58% to 25% (risk ratio (RR) 0.43, 95% CI 0.32 to 0.57; 7 trials, 1149 participants; moderate-certainty evidence). Local adverse events We did not identify any cases of abnormal skin thinning in seven trials that assessed skin thinning (1050 participants) at the end of treatment. We assessed this evidence as low certainty. Other comparisons  Other comparisons included newer versus older preparations of topical corticosteroids (15 trials), cream versus ointment (7 trials), topical corticosteroids with wet wrap versus no wet wrap (6 trials), number of days per week applied (4 trials), different concentrations of the same topical corticosteroids (2 trials), time of day applied (2 trials), topical corticosteroids alternating with topical calcineurin inhibitors versus topical corticosteroids alone (1 trial), application to wet versus dry skin (1 trial) and application before versus after emollient (1 trial). No trials compared branded versus generic topical corticosteroids and time between application of emollient and topical corticosteroids.

AUTHORS' CONCLUSIONS

Potent and moderate topical corticosteroids are probably more effective than mild topical corticosteroids, primarily in moderate or severe eczema; however, there is uncertain evidence to support any advantage of very potent over potent topical corticosteroids. Effectiveness is similar between once daily and twice daily (or more) frequent use of potent topical corticosteroids to treat eczema flare-ups, and topical corticosteroids weekend (proactive) therapy is probably better than no topical corticosteroids/reactive use to prevent eczema relapse (flare-ups). Adverse events were not well reported and came largely from low- or very low-certainty, short-term trials. In trials that reported abnormal skin thinning, frequency was low overall and increased with increasing potency. We found no trials on the optimum duration of treatment of a flare, branded versus generic topical corticosteroids, and time to leave between application of topical corticosteroids and emollient. There is a need for longer-term trials, in people with mild eczema.

Comparison of diflorasone diacetate and betamethasone dipropionate ointment in the treatment of psoriasis

In this double-blind study, 100 patients with mild, moderate, or severe thick lesion psoriasis, characterized as acute, subacute, or chronic, were treated with either diflorasone diacetate ointment 0.05% or betamethasone dipropionate ointment 0.05% twice a day for 3 weeks. Clinical evaluations were based on overall improvement and improvement in signs or symptoms of erythema, oedema, lichenification, induration, scaliness, excoriations, pruritus, and soreness. Results showed that both medications were effective and when patients were categorized according to initial lesion severity no statistically significant differences existed between treatment groups.

Comparative merits of two topical corticosteroid antimicrobial drugs

The anti-inflammatory and antimicrobial activities of two topical creams, one containing halcinonide, neomycin and nystatin (HNN), and the other betamethasone valerate, gentamicin, iodochlorhydroxyquin and tolnaftate (BGI), were compared in a randomized, parallel study of 154 patients (eighty-seven secondarily infected eczematous dermatoses; sixty-seven cutaneous candidiasis). Repeated clinical assessments showed that the two creams produced equivalent therapeutic responses both in patients with infected eczematous lesions and candidiasis. HNN and BGI creams eradicated the bacterial pathogens isolated prior to treatment in 80% and 76%, respectively, of the patients with eczematous dermatoses. The organism most frequently isolated in these patients was S. aureus. Local irritation prompting discontinuance of therapy occurred in just one patient receiving HNN, and two patients receiving BGI.

Comparison of 0.1% halcinonide with 0.05% betamethasone dipropionate in the treatment of acute and chronic dermatoses

A 4-week, bilateral, controlled study was carried out in 53 patients with various acute and chronic dermatoses to compare the effectiveness of 0.1% halcinonide in a water-miscible base, applied once daily, with 0.05% betamethasone dipropionate cream applied twice daily. Patients' response to treatment was assessed at the end of each week. Halcinonide proved to be equally as effective as betamethasone dipropionate in most and superior in some patients with psoriasis, lichen chronicus simplex, and atopic and neurodermatitis. There was also a prompt response to once daily treatment with halcinonide in patients with contact dermatitis, eczema of the hands, and more serious cases of eczema nummulare and allergic skin reactions, many of whom had failed to respond to previous topical steroid therapy. Both preparations were well tolerated and side-effects were noted in only 1 patient with psoriasis whose condition was aggravated by halcinonide. Only 3 patients had a relapse during the 1-month follow-up period after treatment was stopped.

A double-blind comparison of a new combination (halcinonide-neomycin-amphotericin) and active controls in cutaneous candidiasis and steroid-responsive dermatoses

One hundred patients participated in the studies of cutaneous candidiasis and steroid-responsive dermatoses. Seventy patients with the former diagnosis were treated with either halcinonide-neomycin-amphotericin or hydrocortisone-iodochlorhydroxyquin ointment combinations on a double-blind parallel comparison basis. Similar results were obtained after both therapies. Thirty patients with symmetrical bilateral lesions of steroid-responsive dermatoses were treated with halcinonide-neomycin-amphotericin cream on the lesions on one side of the body and hydrocortisone-iodochlorhydroxyquin cream on the opposite side. A double-blind design was used in directly comparing the response to each of the two drugs. Considering the results of all dermatoses together the test combination was statistically superior to the control cream (p less than 0-05). However, while numerical superiority of good responses to the halcinonide combination was recorded in psoriasis, no statistical significance could be derived due to the limited number of cases. No side-effects occurred with any drug combination use. In the opinion of the authors halcinonide-neomycin-amphotericin cream and ointment are safe and effective in the treatment of cutaneous candiasis and steroid-responsive dermatoses.

A comparative clinical evaluation of a new topical steroid 'halcinonide' and hydrocortisone in steroid-responsive dermatoses

Fifty patients with symmetrical, bilateral lesions of psoriasis, eczematous dermatitis, atopic dermatitis, or neurodermatitis participated in a double-blind paired comparison study in which 0-1% halcinonide (in a cream formulation containing also neomycin and nystatin) was applied to the lesions on one side of the body and 1% hydrocortisone cream to those on the opposite side for two to three weeks. The number of excellent responses to therapy showed the halcinonide combination to be significantly superior (p less than 0-01) to the control cream in all diagnostic categories if considered collectively, and in psoriasis if the responses were grouped according to diagnosis. No adverse reactions occurred during the trial.

Comparative efficacy of halcinonide and fluocinonide creams in psoriasis and eszematous dermatoses

The clinical efficacy of halcinonide and fluocinonide creams was compared in the treatment of 392 patients with corticosteroid-responsive dermatoses, including psoriasis, and various eczematous dermatoses such as atopic dermatitis, eczematous dermatitis, and neurodermatitis. The severity of the condition treated was moderate or severe in most of the patients. Usually, the creams were applied three times daily for two to three weeks. In psoriasis, halcinonide was superior to fluocinonide (P less than 0.05). There was no significant difference between halcinonide and fluocinonide in the treatment of the eczematous dermatoses. Both creams were well tolerated, each being associated with local side effects (such as burning sensation, dryness, erythema, and pruritus) in 4.9 per cent of patients.

Comparison of the response of psoriasis, over a 6-month period, to clobetasol propionate and fluocinolone acetonide ointments

Twenty-nine patients with bilateral psoriasis were treated with clobetasol propionate ointment on one side of the body and fluocinolone acetonide ointment on the other in a double-blind clinical trial lasting 6 months. With one exception, after the first month of treatment, all patients responded better on the clobetasol propionate treated side. There was a tendency for any relapses to be less rapid and less severe in clobetasol propionate treated lesions. No adverse effects from either steroid were observed.

Double-blind comparison between two new topical corticosteroids, halcinonide 0.1% and clobetasol propionate cream 0.05%

A new steroid, halcinonide, was compared with clobetasol propionate cream in 100 patients with a variety of skin disorders. The study was conducted as a double-blind, paired comparison with the preparations being given twice daily. Results obtained over a 14-day period of therapy showed remarkably similar efficacy for both preparations.